MEDICARE: MISS NICOLE MARIE BAUKNECHT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085.004867	IL

General Provider Information

NPI Number	:	1255758579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS NICOLE MARIE BAUKNECHT PA-C

Provider Business Mailing Address
First Line	:	1660 FEEHANVILLE DR STE 200
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-6036
Country	:	US
Telephone Number	:	847-823-3185
Fax Number	:	847-823-3318

Provider Business Practice Location Address
First Line	:	984 WILLOW RD STE H
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-6821
Country	:	US
Telephone Number	:	888-938-3838
Fax Number	:	888-919-1083

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2014
Last Update Date	:	04/28/2022

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